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International Journal of Mental
Health Systems
Open Access
Research
Factors affecting mental fitness for work in a sample of mentally ill
patients
Yasser A Elsayed*, Mohamed A Al-Zahrani and Mahmoud MRashad
Address: Al-Amal Complex for Mental Health, Dammam, 31422, Saudi Arabia
Email: Yasser A Elsayed* - yarazek68@gmail.com; Mohamed A Al-Zahrani - mohamedalzahrani1960@gmail.com;
Mahmoud MRashad - mmrashaad@hotmail.com
* Corresponding author
Abstract
Background: Mental fitness for work is the ability of workers to perform their work without risks
for themselves or others. Mental fitness was a neglected area of practice and research. Mental ill
health at work seems to be rising as a cause of disablement. Psychiatrists who may have had no
experience in relating mental health to working conditions are increasingly being asked to
undertake these examinations. This research was done to explore the relationship of mental ill
health and fitness to work and to recognize the differences between fit and unfit mentally ill
patients.
Methods: This study was cross sectional one. All cases referred to Al-Amal complex for
assessment of mental fitness during a period of 12 months were included. Data collected included
demographic and clinical characteristics, characteristics of the work environment and data about
performance at work. All data was subjected to statistical analysis.
Results: Total number of cases was 116, the mean age was 34.5 1.4. Females were 35.3% of
cases. The highly educated patients constitute 50.8% of cases. The decision of the committee was
fit for regular work for 52.5%, unfit for 19.8% and modified work for 27.7%. The decision was
appreciated only by 29.3% of cases. There were significant differences between fit, unfit and
modified work groups. The fit group had higher level of education, less duration of illness, and
better performance at work. Patients of the modified work group had more physical hazards in
work environment and had more work shift and more frequent diagnosis of substance abuse. The
unfit group had more duration of illness, more frequent hospitalizations, less productivity, and
more diagnosis of schizophrenia.
Conclusion: There are many factors affecting the mental fitness the most important are the
characteristics of work environment and the most serious is the overall safety of patient to self and
others. A lot of ethical and legal issues should be kept in mind during such assessment as patient's
rights, society's rights, and the laws applied to unfit people.
Published: 19 November 2009
International Journal of Mental Health Systems 2009, 3:25 doi:10.1186/1752-4458-3-25
Received: 6 October 2009
Accepted: 19 November 2009
This article is available from: http://www.ijmhs.com/content/3/1/25
2009 Elsayed et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
International Journal of Mental Health Systems 2009, 3:25 http://www.ijmhs.com/content/3/1/25
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Background
Mental fitness to work is the ability of workers to perform
their work without risks for themselves or others [1]. It is
an important issue as same as physical fitness. Neverthe-
less, it is a neglected area of practice and research. Mental
ill health at work seems to be rising as a cause of disable-
ment [2]. Assessment of mental fitness is carried out to
prevent future health and safety risks for the worker, cow-
orkers and the public. With the increasing economic bur-
den nowadays and increased awareness by rights of
employees, assessment of mental fitness must be per-
formed with great competence and objectivity; otherwise,
the concerned subjects will feel unfairly treated and will
distrust the outcome of the examination [3]. A good bal-
ance is needed between job opportunities, health and
safety risks. The assessment of fitness for work is not a uni-
versal or static concept as there are a lot of factors that may
impact it. Nevertheless, the absence of adequate training
in this particular field and lack of any published guide-
lines, psychiatrists who may have had no experience in
relating mental health to working conditions are increas-
ingly being asked to undertake these examinations. Many
psychiatrists sought empirical ways of assessment and
decision making to achieve this mission and gained expe-
rience with time. Motivated by all the above issues, this
study was done to; a) explore the relationship between
mental illness and fitness to work, b) detect the important
factors affecting mental fitness to work, c) identify the dif-
ferences between fit and unfit mentally ill patients and
lastly this study was a trial to translate the experience
gained during years of work in such field into objective
guidelines for assessment and decision making.
Methods
This study was a cross-sectional one and was done in Al-
Amal Complex for Mental Health, located in Dammam.
The complex belongs to the Ministry of health, Kingdom
of Saudi Arabia (KSA). The forensic psychiatry committee
is one of the important units inside the complex. The
committee has a dual obligation work, toward the patient
and the referring agency. Among the reasons of referral to
this committee are forensic problems, cases in need for
legal guardian and assessment of mental fitness to work.
Yearly, there are about 1000 cases received for assessment
from different sources. The committee is operated by a
multidisciplinary team. All the investigators are members
in this team for many years. This study was approved by
the scientific and ethical committee of Al-Amal Complex
for Mental Health and informed consent was taken from
the all subjects. All cases referred to the committee for
assessment of mental fitness during a period of 12 months
were recruited into the study. Data was obtained from
interviews with patients themselves, caregivers, psychiat-
ric files and reports from the employers. Information
obtained included sociodemographic data, clinical varia-
bles, and history of treatment including previous hospital-
ization. Moreover, global assessment of function (GAF)
scale [4] was applied for all subjects. To assess the work
environment characteristics and behavior at work, the
investigators included both subjective and objective data.
The subjective data was obtained through application of
some items from world health organization health and
performance questionnaire (WHO-HPQ) [5] which was
designed originally to provide information to employers
about the indirect costs of untreated and under-treated
employee's health problems. It is a brief self-report ques-
tionnaire that obtains information about sickness
absence, productivity, critical incidents and work related
accidents. The objective data was obtained through a list
of items created by the investigators after reviewing the lit-
erature related to this topic [2,3,6,7]. The list included:
level of productivity at work, level of disturbed relation-
ships with colleagues, risk of physical hazards at work,
level of public communications needed at work, degree of
dealing with finances, degree of supervision over work,
work load, and presence of disturbed behaviors at work.
Each point was scored by the investigators low, intermedi-
ate or high according to information obtained from all
sources listed above. Also, the list included; years of expe-
rience, distance between home and work in kilometers,
presence of afternoon and night shifts, and absenteeism
in the last year in days. All diagnoses were made according
to mini-international neuropsychiatric interview
(M.I.N.I.) which is a short structured diagnostic interview
[8]. However, diagnoses of organic mental disorders and
personality disorders were based on ICD-10 research diag-
nostic Criteria [9] and were validated by two consultant
psychiatrists with good inter-rater reliability. In case of
comorbidity, the investigators identified the primary diag-
nosis and comorbid diagnosis. Each subject was inter-
viewed by the investigators at least once and some
patients needed more sessions to finalize their assess-
ment. At the first assessment visit, all patients were
informed of 6 important issues; 1) who invited the com-
mittee to see him/her, 2) what the committee does profes-
sionally (team and different specialties), 3) the purpose of
the examination. 4) What information the committee has
already been given, 5) what is known and relevant to the
report may not be regarded as confidential between
patient and committee (the right of the committee to dis-
close information to employer), and 6) how the report
may be used with or against the person. At the end of
assessment, each subject was asked to rate his/her satisfac-
tion level with decision of the committee and scored
appreciating, not appreciating, or indifferent.
All the data was subjected to statistical analysis using SPSS
version 10.0. The main findings are presented as propor-
tions with 95% confidence intervals. According to the
decision of the committee, the subjects were further clas-
sified into three groups; fit, unfit, and modified work
groups. Comparisons were done using means, standard
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deviations, frequencies, Kruskal Wallis and ANOVA. Level
of significance was detected at p value 0.05.
Results
Subject characteristics
Total number of cases recruited through 12 months dura-
tion was 234 cases, of which, only 116 cases agreed to give
consent and their data was completed. The mean age was
34.5 1.4 years. Characteristics of the sample and diag-
noses are presented in table 1 and 2. The decision of unfit
to work was temporary in 10 cases (43.5%) and perma-
nent in 13 cases (56.5%)while the decision of fit for mod-
ified work was temporary in 21 cases (65.6%) and
permanent in 11 cases (34.4%).
Comorbidity was found in 49 cases; psychiatric comor-
bidity in 34 cases (29.3%) and physical comorbidity in 15
cases (12.9%).
There were significant differences between fit, unfit, and
modified work groups in a number of parameters as
shown in table 3, 4 and 5. There were no statistically sig-
nificant differences between groups as regard GAF, work-
ing hours, work load, deal with finances, years of
experience and number of workers supervised by the
patient.
All patients diagnosed as conversion or somatoform dis-
orders and all malingerers were fit. There were no signifi-
cant differences between groups regarding the following
diagnoses; anxiety disorders, bipolar disorder, and
organic mental disorders. Also, there were no statistically
significant differences between groups as regard duration
of treatment, use of mood stabilizers, atypical antipsy-
chotic drugs or polypharmacy.
Discussion
Assessment of mental fitness for work is considered in
three main conditions; return to work after being off work
for a period of time due to mental illness, request from the
employee or employer for assessment and lastly recruit-
ment of new staff. The current study has focused on the
Table 1: characteristics of the subjects
Item Results
Age mean & SD 34.5 3.8
Men n & % 75 (64.7%)
Females n & % 41 (35.3%)
Single n & % 38 (32.8%)
Married n & % 78 (67.2%)
Reason of referral Disturbed behavior at work 71 (61.3%)
Request from the patient 45(38.7%)
Education level High 59 (50.8%)
Intermediate 32(27.5%)
Low 25 (21.5%)
Decision n & % Fit 61 (52.5%)
Unfit 23 (19.8%)
Modified work 32 (27.7%)
Satisfaction with the decision Appreciated 34 (29.3%)
Not appreciated 66 (56.9%)
n, number of subjects; %, percentage; SD, standard deviation
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first and second conditions because they are the most sen-
sitive and the most commonly referred cases to the foren-
sic committee. In this study, the goal of assessment of
each subject was to reach one of three decisions either fit
for regular work, unfit for work, or lastly fit for wok with
certain modifications in the work environment. The
forensic committee took the decision of fitness to work
according to consensus of all members of the multidisci-
plinary team including the investigators that's why this
study is a trial to translate this experience into guidelines
that are as objective as possible for such assessment and
decision making.
The ways in which subjects are assessed for mental fitness
are always questionable as there are conflicts of interest in
the sources of data (the patient and the employer). That's
why the investigators listened to patients and asked the
employers for reports and put their own assessment of the
work environment characteristics. Nevertheless, 56.9% of
the subjects didn't appreciate the decision of the commit-
tee. This is an important aspect of dual obligation work as
always there is unsatisfied side. Lack of appreciation may
lead in many cases to lawsuits against the team.
Characteristics of the sample
The mean age of the subjects referred was 34 3.8 years.
This age is the most productive time of the person's life
[10]. It means that each subject has at least an average 25
years till the age of retirement which makes the decision
of unfit to work difficult and expensive decision. Men
constitute 64.7% of the sample and women 35.3%. This
difference is not significant because the rate of employ-
ment for women is much less than employment for men
in KSA [11]. Also, 32% of the cases were single which may
be attributed to delayed marital age especially in mentally
ill patients. Although the sample included subjects from
all educational levels, 50.8% of referred cases were highly
educated. This sounds logic as subjects who are highly
educated usually work in important positions and are
more easily detected when they become mentally ill [12].
While mentally ill patients with low educational level usu-
ally take longer time to be detected because they com-
monly work in simple jobs.
Substance abuse and dependence was the most prevalent
diagnosis (20.7%) among the referred sample. These
patients are usually disturbing for others, irresponsible
and have a lot of troubles at work [13-15]. Moslem's cul-
ture strictly prohibits use of all substances including social
drinking. That's why many employers can tolerate pres-
ence of some mentally disabled workers but never to
accept substance users.
The second common diagnoses were schizophrenia and
delusional disorders (14.7%). This may be explained by
failure of schizophrenic subjects to adapt to their work.
Their disturbed behaviors are easily detected and conse-
quently they lose their jobs. Schizophrenics are among the
most discriminated against of all disabled people. In the
current study, unfit schizophrenic cases constituted 47%
which is similar to the rate of unemployment among
schizophrenics in a British study [15].
The most commonly presented anxiety disorder was
social phobia (n 12 = 10% of the sample). This rate is
accepted due to increased rate of social phobia reported in
Saudi Arabia [16]. The rate of major depressive disorder
was unexpectedly low (13.8%) in comparison to western
studies of functional impairment of mentally ill people
[13,17]. This result may be explained culturally as many
cases of depression respond well to traditional treatments
and adapt easier than patients with schizophrenia, sub-
stance abuse or social phobia.
There was a high rate of comorbidity (42.2% of cases)
which was consistent with Gerkin's study [18] who
reported that combinations of mental ill health, substance
misuse, and chronic physical illness produce more disa-
bility days than would be predicted by adding their com-
ponent effects.
Table 2: Current diagnoses
Diagnosis n & (%)
Schizophrenia and delusional disorders 17 (14.7%)
All Subsances of abuse 24 (20.7%)
Amphetamine 18 (15.5%)
Major Depressive disorder 16 (13.8%)
Bipolar disorder 5 (4.3%)
Anxiety disorders 15 (12.9%)
Social phobia 12 (10%)
Adjustment 11 (9.5%)
Conversion and dissociation 3 (2.6%)
Somatoform disorders 4 (3.4%)
Personality disorders 10 (8.6%)
Organic mental disorders 3 (2.6%)
Malinger 8 (6.9%)
Comorbidity mental and physical 49 (42.2%)
n, number of subjects; %, percentage
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Despite the majority of mental patients in this sample
were addicts and schizophrenics, yet, the tendency of
committee decision was towards fitness to work (either
full fitness or modified fitness) more than unfitness. This
may emphasize that having mental illness in a subject
doesn't necessarily indicate that he/she is unfit to work. It
further points to the notion that there are other capability
factors that affect the ability of the person to work rather
than just having mental illness per se.
Table 3: comparisons between groups
Characteristics Fit
n 61
Unfit
n 23
Modified
n 32
P
value
Age in years, mean SD 31.88 (11.6) 39.58 (10.5) 30.19 (9.4) 0.043
Education, mean SD 12.9 2.61 7.5 3.51 9.4 2.8 0.05
Duration of illness years, mean SD 3.8 1.92 10.12 2.35 4.2 3.41 0.01
Hospital days, mean SD 9.03 4.15 58.9 18.21 15.03 12.04 0.001
Age at onset, mean SD 23.0 (8.9) 19.0 (8.6) 23.5 6.5 0.062
Hospitalized in past year, % & (n) 26.2% (16) 56.5% (13) 31.2% (10) 0.05
Absenteeism at last year in days, mean SD 24.6 3.13 66.4 2.13 33.2 3.41 0.01
High Physical hazards at work, % & n 18% (11) 47.8% (11) 68.8%(22) 0.03
Presence of afternoon and night shifts, % & n 31.1%(19) 43.5%(10) 56.2% (18) 0.05
The work need high level of communication with public, % & n 19.8% (12) 34.8% (8) 15.6%(5) 0.05
High level of Disturbed Relationship with colleagues, % & n 47.5%(29) 78.3%(18) 50% (16) 0.05
Low Productivity at work, % & n 32.9% (20) 91.3%(21) 59.4% (19) 0.05
Years of experience, mean and SD 14.4 4.5 17.3 3.6 13.5 2.9 0.554
n, number of subjects; %, percentage; SD, standard deviation
P value is significant at 0.05
Table 4: Items from WHO health and work performance questionnaire
Characteristics Fit
n 61 (%)
Unfit
n 23 (%)
Modified
n 32 (%)
P value
An accident or event that caused either damage, work delay, a near miss, or a safety
risk in the last month
18(29.5%) 12 (52.2%) 20(62.5%) 0.04
An experience of work failure at the last month 38 (62.3%) 8(34.8%) 22(68.8%) 0.05
doing no work at most of the work time 13(21.3%) 18 (78.3%) 17(53.1%) 0.03
Work performance at last year 7 out of 10 7 (11.5%) 15 (65.2%) 5 (15.6%) 0.003
Better overall job performance during the past year in comparisons to other
workers
5 (8.2%) 16 (69.6%) 4 (12.5%) 0.001
Worse overall job performance during the past year in comparison to other workers 50 (82%) 3 (5%) 23 (71.9%) 0.001
n, number of subjects; %, percentage
P value is significant at 0.05
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Comparisons between groups
The productivity of all groups was impaired but relatively
the fit group had less impairment than other groups. The
most common psychiatric disorders reported among the
fit group are adjustment, personality and depressive disor-
ders with the least comorbidity rates. While the unfit
group consisted mainly of schizophrenic subjects and
reported the highest comorbidity rates. Meanwhile, the
modified fitness group was mainly substance use subjects.
These findings suggest that the type of psychiatric diagno-
sis may have direct relation to fitness to work. Further-
more, Bullying is often identified [15] especially in
malingerers and minor psychiatric disorders. This
explains why 100% of subjects with conversion and
somatoform disorders in addition to malingerers in the
current study were given fit decision.
The fit group had significantly shorter duration of illness,
younger mean age, shorter mean hospitalization time, less
frequent hospitalization in the last year and less frequent
absenteeism. These findings could be simply explained by
differences in the stage of illness that might disappear
after few years of chronicity. Also, these findings might
indicate less severity of illnesses, hence less impairment of
function. Moreover, the fit group was significantly more
educated, had little physical hazards in their works, and
little afternoon or night shifts. These data appear logic as
educated people have more reserve and more power of
adaptation to illnesses [19] and usually work in better
positions with less physical hazards and work is only one
morning shift.
Interestingly, 40 cases of the fit group used antidepressant
drugs while actually only 25 cases diagnosed with depres-
sion and anxiety disorders. This is explained by either
increased use of antidepressant drugs in cases like conver-
sion, substance abuse and adjustment disorders or due to
actual improvement in function with use of antidepres-
sants [20].
The unfit group had more duration of illness, more fre-
quent hospitalizations in the last year, more hospitaliza-
tion days, more need for communication with the public
during work, more disturbed relationship with their col-
leagues, less productivity, more comorbidity and more
diagnosis of schizophrenia. These results seem to be
related to each other. In contrast to the fit group, the unfit
group had less use of antidepressant drugs and more use
of conventional antipsychotic drugs which may be due to
either overrepresentation of subjects with psychosis in the
group or actual impairment in function by conventional
antipsychotic drugs and lack of antidepressant drugs [21].
Table 5: comparisons between groups as regard diagnoses and drugs received
Characteristics Fit
n 61
Unfit
n 23
Modified
n 32
P value
Substance % & (n 24) 29.1% (7) 16.6% (4) 54.2% (13) 0.004
Schizophrenia % &(n 17) 29.4% (5) 47% (8) 23.6% (4) 0.005
Depressive disorder % (n 16) 62.5% (10) 12.5%(2) 25% (4) 0.001
Adjustment % (n 11) 90.9% (10) 00 9.1% (1) 0.001
Personality disorders % (n 10) 80% (8) 10% (1) 10% (1) 0.001
Comorbidity % (n 49) 20.4% (10) 46.9% (23) 32.7% (16) 0.02
Antidepressants drugs % & (n) 65.6%(40) 17.4%(4) 56.%(18) 0.01
Typical antipsychotic drugs % & (n) 4.9%(3) 43.5%(10) 6.3%(2) 0.005
Use of Mood stabilizers % & (n) 16.4% (10) 17.4% (4) 15.6% (5) 0.241
Use of atypical antipsychotic drugs % & (n) 29.5% (18) 34.8% (8) 31.3% (10) 0.064
Use of polypharmacy % & (n) 67.2% (41) 73.9% (17) 59.4% (19) 0.445
n, number of subjects; %, percentage
P value is significant at 0.05
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The decision of unfitness to work was either temporary or
permanent. Temporary unfit means the patient will be
given sick leave and reassessed again after suitable time.
Permanent unfit is the most difficult decision as it means
that the employee will never be fit for the job and that
employee is unable to do any available job, with or with-
out work modifications.
On the other hand, the decision of work environment
modification was given to those patients who had contro-
versies between the two other groups. This group signifi-
cantly had more physical hazards in work environment,
more afternoon and night shifts and more frequent diag-
nosis of substance abuse and dependence. Actually, diag-
nosis of substance abuse is a serious diagnosis hindering
any work as patients may abuse drugs during work and
became dangerous to themselves and others. It is worth
mentioning that the commonest substance of abuse in the
current study and in the region was amphetamine, with
relatively high rate of amphetamine induced psychosis
[22]. Also, a judgment in this category means the
employee would be a hazard to self or others if employed
in the job as described by his/her employer but would be
considered fit to do the job if certain working conditions
were modified. The modifications required must be
clearly described. Again, the decision is either temporary
or permanent. Temporarily means that if the person's con-
dition improves with time, the decision may be lifted. Per-
manent work modification means that the employee will
never be fit for the job without these modifications.
Unfortunately, there is no uniformly applicable psychiat-
ric wheelchair ramp [3]. Modifications might include
shortening of working hours, reduction of work load,
graded resumption of responsibilities, working away from
physical hazards or providing strict supervision for those
who abuse substances [23,24]. Nevertheless, work modi-
fication may interfere with the schedule of others and add
to their workload and may lead to further discrimination
by co-workers. That's why this decision should be time
limited as much as possible.
Surprisingly, it was found that 65.2% from the unfit group
scored 7 or more out of 10 for their job performance dur-
ing the last year in comparison to 11.5% and 15.6% for
the fit group and the modified work group respectively.
Also, 62.3% of the fit group and 68.8% of the modified
work group had an experience of work failure in the last
month while only 34.8% of the unfit group had the same
experience. These results express the way each subject
evaluates him/herself and the degree of the discrepancy
between the decision of the committee and patients' satis-
faction and expectations. They also reflect to what extent
subjects may distrust such assessment. For instance, most
unfit schizophrenics have high expectations to work, in
contrast to most of fit non psychotic patients. The same
issue was repeated again in answer to a question "how
would you compare your overall job performance during
the past year with the performance of other workers who
have a similar type of job? The answer was better than
other workers in 69.6% for the unfit group. This indicates
that self rating questionnaires are not valid or reliable
ways to assess mental fitness. Another finding from the
WHO health and work performance questionnaire was
that 52.2% of the unfit group and 62.5% of the modified
work group had an event that caused either damage, work
delay or safety risk in the last month. This finding sup-
ports the decision of the committee. Moreover, in answer
to the question "How often did you do no work at times
when you were supposed to be working?" 78.3% of the
unfit group found themselves doing no work when they
were supposed to be working. This denotes the degree of
tolerance in the work environment, either these patients
don't really work or their supervisors don't rely upon their
work most of time, which again supports the decision of
the committee.
There are many other factors that are difficult to measure
and should be considered in assessing mental fitness to
work. One important factor is the ethical factor, balancing
between patient's rights, employer's rights and society's
rights. Another factor is the impact of decision on
patients' lives like the maximum duration of sick leave
that can be given, the extent to which patients will be
compensated if they become unfit for work and the social
influences on the employee upon given this decision.
Lastly, there are a lot of cultural differences in tolerating
mentally ill people in different jobs. Generally, the Arab
culture is more tolerant for mentally ill people and the
concept of work productivity is not clear for workers or
employers especially in governmental jobs [25] which
again explain why 78.3% of the unfit group found them-
selves without work most of the time in the last year. In
addition, Arab countries usually allow for over-employ-
ment [26] in simple jobs, hence productivity is compro-
mised even in healthy people. That's why the fitness
decision is related to the culture, the place of work and the
nature of employer.
Although there seems to be a growing interest in the field
of assessment of fitness for work [27], yet, the literature is
still very scarce and rarely based on experimental design
[28]. One of the difficulties encountered in this study is
the unclarity of research designs in this area. This could
probably be owing to the complexities of such assessment
with regard to its conceptual constraints, ethical implica-
tions and difficulties related to methodological aspects.
Many subjects refused to give consent for the study which
represented a challenge for such kind of research. One of
the problems that faced the investigators is the underde-
velopment of risk management strategies in different
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associations in addition to lack of occupational health
staff which made the communication with employers dif-
ficult and time consuming. Also, data presented to the
committee team usually deficient and incomplete. More-
over, lack of satisfaction of patients is an important prob-
lem in this field. Another limitation is that the current
study didn't pay attention to the level of stress outside the
work which is an important influential factor. Although
this study presents a general cross-sectional design, the
tools used are used for the longitudinal evaluation of past
functioning. It would be interesting to take into account
the fact that retrospective data might be memory biased.
Occupations were not listed in the results as the investiga-
tors gave more importance to characteristics of work envi-
ronment and found this easier to do comparisons. Many
occupations were presented in the current study as teach-
ers, soldiers, engineers, technicians, machinists, nurses,
etc. But the number of subjects in each occupation was
too little to do analytical statistics. However, there are
many influential factors related to occupation and need
attention in separate studies.
Conclusion
There is a general belief that the psychiatrist should find
the balance between loyalty to the patient and the duty of
employers to offer safe effective service. System with
greater communication, cooperation and understanding
between the psychiatrist, the personnel department, the
supervisor and other health professionals is strongly rec-
ommended but confidentiality is often reported as a bar-
rier. Legislation shows that employers need to be aware of
the relapsing and remitting nature of mental disorders
and the potential for adjustments. Psychiatrists should
bear in mind that the validity and effectiveness of judg-
ments on unfitness for work are still doubtful and incon-
sistent. Standardized criteria are strongly needed and
enabling options should always be considered.
The assessments of fitness for work should focus on job
requirements more than focusing solely on medical diag-
noses. So before assessment of the patient, data about
characteristics of working environment must be available.
The most specific and important information according to
the current study were level of physical hazards, presence
of afternoon and night shifts, level of public communica-
tion needed, relationship with colleagues, productivity
and absenteeism. However, other factors cannot be
excluded by only one study on 116 cases. That's why fac-
tors like working hours, work load, leadership skills
needed, work in finances, duration of service, job location
and degree of supervision should be considered. At the
same time, the criteria used to evaluate fitness should
include ethical, economic and legal considerations. Being
unemployed is associated with high level of psychiatric
morbidity as the working environment can be an impor-
tant determinant of both mental ill health and, for many,
wellbeing.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
All authors conceived of the study and participated in its
design and coordination. YAE administered the instru-
ment and collected the data. MAA directed and oversaw
the statistical analysis. MMR participated in data collec-
tion and conducted statistical analysis. All authors partic-
ipated in the writing and revision and approved the final
manuscript.
Acknowledgements
The authors acknowledge the efforts of all the staff of the forensic commit-
tee of Al-Amal Complex For Mental Health, Dammam, KSA in particular
the dedicated efforts and support of Dr Waleed Al-Mulhim and Dr
Mohamed Shaaban. The study was presented and published as an abstract
in 162
nd
Annual meeting of American Psychiatric Association in San Fran-
cisco in May 2009.
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